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- MO W <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CAI S� r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This <br /> made a compliance with San Joaquin County 0Ord'+Hance No. 549 far sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. j-.. r� <br /> PM <br /> l r Lot Size lJ (� City <br /> Job Address <br /> d Phone <br /> Address - <br /> Owner's Name <br /> - License No. Phone <br /> Contractor ;1 Address <br /> F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION D <br /> SYSTEM REPAIR ❑ OTHER El <br /> SEWER LINES .�_--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEARE SEPTIC,TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k OUNDATION <br /> INTENDED USE T OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> - ❑ Open ttom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> 0 Domestic/Private ❑ Gravel Pac ❑ Tracy Type o -Type of Grout - <br /> z Cl Other j ❑ Delta Depth o1 Grout Seal <br /> f 1 Public <br /> Approx.-Depth astern Surface Seal Installed by <br /> I I Irrigation — r H.P. State Work Done _ <br /> Repair Work Done ❑ Type of t Sealing Material itop 50'1 <br /> Well Destruction <br /> all Diameter �. <br /> Depth IW'Material (Below 50'1 <br /> TYPE OF SEPTIC WORK:, NEW INSTALLATION i.1 REPAIR/ADDITION { I DESTRUCTIO No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> a <br /> k <br /> Installation will serve: Residence . Commercial -,G,Other <br /> Number of living units: b <br /> Numer of bedrooms Water table depth <br /> y Character'of soil to a depth of 3 feet: No. Compartments <br /> f ❑ Type/Mfg Capacity <br /> SEPTIC TANK Method of Disposal <br /> I PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well <br /> Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED © Dista <br /> rice'to nearest: Well Foundation P v <br /> j » <br /> Size Number <br /> SEEPAGE PITS l I Depth Property Line <br /> r SUMPS Ll Distance to nearest: Well Foundation P Y <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the following: ." Contractors hiring or sub contracting signature <br /> '9 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become.subject to workman's compensation laws of California <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 4 <br /> The applica <br /> nt t mus call for all required inspection Complete drawing on reverse side. Date: /a <br /> Title: <br /> Signed X - <br /> F. PEPARTM NT USE ONLY - _�d r / <br /> + Date Area <br /> Application Accepted by - <br /> Pit or Grout Inspection by (late <br /> Final lnspaction by T- Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .O Tracy 835-6385 <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ' <br /> FEE' AMOUNT DUE AMOUNT REMITTED C ASH RECEIVED BY DATE PERMIT NO. <br /> INFO �p / <br /> ♦.EH 13-24 IREV.t/w 51 'lr - �3 C(JJ <br /> EH 14-26 <br />